Level A

What Do Your Choices Mean?

If you score in Level D in any area, your practice is just getting started and may want to review our resources page to help you prepare for the key changes described in that section of the guide.

If you score in Level C in any area, your practice is in the early stages of change and can benefit from the action steps and resources in that section of the guide.

If you score in Level B in any area, your practice has implemented basic changes and can build upon your success with the action steps and resources in that section of the guide.

If you scored in Level A in any area, your practice has achieved most or all of the important changes required. Congratulations! You can still use the actions steps and resources in that section of the guide to find new ways to improve.

What is the challenge?

Patients with more complicated physical and/or mental illnesses are at increased risk of potentially serious, even fatal, exacerbations and complications. They may benefit from more intensive follow-up and management than can be done through repeated office visits. Many patients being discharged from the hospital or Emergency Department fit this description. Evidence suggests that well-organized care management by a nurse or other health professional can reduce patients' risk of deterioration and readmission, and the associated health care costs. One-half of patients readmitted to hospitals within 30 days of discharge have not seen a community provider.

Implementing Effective Clinical Care Management

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Learn more about complex care management at this website, from the Safety Net Medical Home Initiative. The information is relevant to all types of practices, not just those in the safety net.

What do we gain by making these changes?

With effective care management, your practice can improve disease control and self-management, reduce distress, prevent admissions or readmissions, and improve the coordination of care for more complex patients. Care management contributes significantly to a practice’s ability to reduce total costs of care.

Effects of Nurse-Managed Protocols in the Outpatient Management of Adults with Chronic Conditions

Learn about the evidence for expanding the role of nurses in chronic disease management, based on a literature review conducted by the Department of Veterans Affairs when developing its Patient-Aligned Care Team (PACT) model.

Patients with a wide variety of clinical and behavioral problems may benefit from care management. Patients with mental health problems and/or social and economic challenges may also benefit from case management services from a social worker. Less complicated patients needing only closer monitoring can be followed effectively by a trained MA or lay person using a protocol and supported by a health professional.

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Role features

Care Coordinator Job Responsibilities

Learn about the responsibilities of the care coordinator at one LEAP site. Working with a nurse care manager, the MA care coordinator supports care management focused on the highest-risk patients.

RNs have become much less common in primary care practice settings. But many still spend much of their day fielding incoming phone calls and giving injections. Many LEAP practices are finding different ways to manage phone calls (see communication management module) and injections to free up RN time for care management. Additional training may be necessary for some RNs to play this new role.

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Staff training

RN training materials

Learn more about training that can support RNs to work to the top of their license, including to provide care management to highest-risk patients, in the RN topic of the Primary Care Team Guide.

Most care management programs target patients with high costs and/or high utilization, and many use computerized risk prediction algorithms to identify candidates. Others focus on patients being discharged from the hospital or patients referred by providers in the practice. The practice should be clear which patients it wants to target, but payers generally expect total cost reduction through reduced hospitalizations and Emergency Department (ED) visits.

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Clinical protocol

Risk Stratification using a modified LACE Tool

See how one LEAP site, Penobscot Community Health Care (PCHC), risk stratifies patients to direct the level of services needed for patient with complex health conditions. The highest risk patients are admitted to a robust complex care management program, then assessed using the modified LACE tool. PCHC developed a workflow involving the MA Health Coach, RN Care Manager, and social worker who are part of the complex care management team.

Establish relationships with key hospital(s) to identify and co-manage patients discharged from the hospital.

To effectively support patients through transitions, practices need to know as soon as possible when their patients are seen in the ED or hospitalized. This often requires that the practice initiates conversations with hospital/ED administrators and care management staff to ensure early notification and coordination of post-discharge care.

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Clinical protocol

Hospital Pre-Discharge Virtual Patient Interview Protocol

Learn how one LEAP site connects with patients while still in the hospital, to begin coordinating the transition. West County Health Centers uses technology to facilitate a more personal connection when possible.

Hospital Pre-Discharge Virtual Patient Interview Workflow

Learn how one LEAP site connects with patients while still in the hospital, to begin coordinating the transition. West County Health Centers uses technology to facilitate a more personal connection when possible.

Hospital Transition Overview

Learn about one LEAP site's organizational approach to care transitions in this document, which reflects the commitment to collaborating with all of the hospitals where a majority of their patients seek care and having a process for timely information exchange with each hospital. Leadership, providers, and nurses all have a critical role in creating and maintaining processes so that patients experience a smooth transition across care settings.

Post-Emergency Department Follow-Up

Learn more about follow-up after an Emergency Department visit at this website, from the Safety Net Medical Home Initiative. The information is relevant to all types of practices, not just those in the safety net.

Transition Care Clinical Protocol

High-Risk Case Management Overview

Learn about the high-risk case management approach at one LEAP site, in determining how to best allocate different types of team-based care to patients based on their level of risk and need. You can find protocol related to the high-risk case management services in our collection of tools in this topic

To ensure that a care management program is effective, it’s important to create protected time for nurses or other care management staff. If they get pulled away to cover the phones or do a dressing change, the essential work of care management will not get done. Having leadership support for protected time is essential.

Develop a support structure for care managers.

Most successful care management programs ensure that nurses regularly review their cases with relevant clinical experts. This could be with a multi-disciplinary team that includes a provider or other clinician, social worker, behavioral health specialist, clinical pharmacist, or others. Or the practice can designate a consulting clinician (other than the primary care provider) for this role. In addition, nurse care managers have major documentation and administrative burdens and often need help meeting their patients’ social needs. In response, several LEAP sites have linked nurse care managers with MAs, administrative staff, or social workers.

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Clinical protocol

RN Complex Care Management Case Conference Clinical Protocol

See protocol used by nurse care managers at one LEAP site to conduct a multidisciplinary case conference review of patients in the complex care management program who need a new or revised care plan. The Nurse care manager invites relevant clinical experts, which includes the provider, MA, behavioral health specialist, or pharmacist, depending on the cases being discussed.

Case Conference Description

Learn about one LEAP site's approach to multidisciplinary case conference reviews of patients in the complex care management program. The nurse care manager invites relevant clinical experts, including the provider, MA, behavioral health specialist, or pharmacist, depending on the cases being discussed. Each team member brings different types of insight and suggestions for making improvements to the patient's care plan.

Complex Case Management Care Plan

Learn about one LEAP site's approach to multidisciplinary case conference reviews, by looking at the care plan notes from one of these sessions for patients in the complex care management program. The nurse care manager invites relevant clinical experts, including the provider, MA, behavioral health specialist, or pharmacist, depending on the cases being discussed. Each team member brings different types of insight and suggestions for making improvements to the patient's care plan.

Learn about the evidence for expanding the role of nurses in chronic disease management, based on a literature review conducted by the Department of Veterans Affairs when developing its Patient-Aligned Care Team (PACT) model.

Post-Emergency Department Follow-Up

Learn more about follow-up after an Emergency Department visit at this website, from the Safety Net Medical Home Initiative. The information is relevant to all types of practices, not just those in the safety net.

High-Risk Case Management Overview

Learn about the high-risk case management approach at one LEAP site, in determining how to best allocate different types of team-based care to patients based on their level of risk and need. You can find protocol related to the high-risk case management services in our collection of tools in this topic

Case Conference Description

Learn about one LEAP site's approach to multidisciplinary case conference reviews of patients in the complex care management program. The nurse care manager invites relevant clinical experts, including the provider, MA, behavioral health specialist, or pharmacist, depending on the cases being discussed. Each team member brings different types of insight and suggestions for making improvements to the patient's care plan.

Complex Case Management Care Plan

Learn about one LEAP site's approach to multidisciplinary case conference reviews, by looking at the care plan notes from one of these sessions for patients in the complex care management program. The nurse care manager invites relevant clinical experts, including the provider, MA, behavioral health specialist, or pharmacist, depending on the cases being discussed. Each team member brings different types of insight and suggestions for making improvements to the patient's care plan.

Risk Stratification using a modified LACE Tool

See how one LEAP site, Penobscot Community Health Care (PCHC), risk stratifies patients to direct the level of services needed for patient with complex health conditions. The highest risk patients are admitted to a robust complex care management program, then assessed using the modified LACE tool. PCHC developed a workflow involving the MA Health Coach, RN Care Manager, and social worker who are part of the complex care management team.

Hospital Pre-Discharge Virtual Patient Interview Protocol

Learn how one LEAP site connects with patients while still in the hospital, to begin coordinating the transition. West County Health Centers uses technology to facilitate a more personal connection when possible.

RN Complex Care Management Case Conference Clinical Protocol

See protocol used by nurse care managers at one LEAP site to conduct a multidisciplinary case conference review of patients in the complex care management program who need a new or revised care plan. The Nurse care manager invites relevant clinical experts, which includes the provider, MA, behavioral health specialist, or pharmacist, depending on the cases being discussed.

WorkflowTemplates, flow sheets and mapping aids

Workflow

Hospital Pre-Discharge Virtual Patient Interview Workflow

Learn how one LEAP site connects with patients while still in the hospital, to begin coordinating the transition. West County Health Centers uses technology to facilitate a more personal connection when possible.

Hospital Transition Overview

Learn about one LEAP site's organizational approach to care transitions in this document, which reflects the commitment to collaborating with all of the hospitals where a majority of their patients seek care and having a process for timely information exchange with each hospital. Leadership, providers, and nurses all have a critical role in creating and maintaining processes so that patients experience a smooth transition across care settings.

If you have a question about the improvements, action steps, or tools & resources in this module please let us know. We're here to help. And if we can't answer your question, we can probably connect you with someone who can.